Hoe zorginformatiebouwstenen de wereld veroveren Dr. William Goossen Projectleider ISO 13972 DCM
Overzicht • • • • •
Noodzaak voor generieke “reusable bits” 15 jaar waarde toevoegen aan klinische modellen Detailed Clinical Models als verzamelterm HL7 / ISO / CEN / JIC projecten Actuele projecten
2
Structure characteristics: service items environment context
Layer 5 international MDS Layer 4: MDS: national purposes
Aggregatie Business level Policy decisions
Layer 3: Use of Data Sets for research, quality or management reporting Unified terminology for comparable data
Layer 2: documentation of: Problems / diagnoses interventions Outcomes of care
Use case leve Management / research decisions
Composition level
Layer 1: Facts: - Demographical data - Observations: signs & symptoms - Aetiology: facts causal relations / data other disciplines etc.
Clinical decisions
DCM level (Goossen, 1996)
Internationaal werk: ‘90 • Rector,
Kay et al, 1992: two level modeling • CEN ‘general purpose information components’ (GPICS) • CEN 13606 – 2 ‘Archetypes’ • HL7 v3 CDA / messaging ‘templates’
Vroege 2000’s • • • • • • • • •
Nictiz perinatologie R&D project 2000 – 2005 HL7 v3 D-MIM Care Provision 2005 – 2007 Dynamiek van zorgprocessen: real time R-MIM transfer request / acceptance R-MIM query R-MIM care record R-MIM subcomponenten Herbruikbare componenten als clinical statements 2005-2009 (CDA en v3 Care Record!) Structuren zoals assessment scales DSTU 20112014, naar normatief 2016?
Screening in Europe
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Nationaal hergebruik • •
•
Voorbeelden Care Provision projecten Natuurlijk lengte, gewicht, hartslag, bloeddruk hergebruik van Nictiz perinatologie naar Nictiz CVA ketenzorg en ook cardiologie. Goedkoper, meer consistent, sneller project resultaten! Geharmoniseerd met NICTIZ trauma project en LOINC 22 juni 2005 WG
CVA voorbeeld • Glasgow Coma Scale (GCS) • Geharmoniseerd met GCS Nictiz trauma project. •
GlasgowComaScale ((NICTIZ_2004_GCSrev0.94June05) )
Glascow Coma Scale v.0.95
Choice EMV_score_total classCode*: <= OBS moodCode*: <= EVN code: CD CWE [1..1] <= LogicalObservationIdentifierNamesAndCodes "LOINC 9269-2" derivationExpr: ST [0..1] "Sumscore" effectiveTime: TS [0..1] value: ST [0..1] interpretationCode: SET
CWE [0..*] <= ObservationInterpretation (E-M-V 4-6-5 = normaal; 1-5-2 = coma)
GCS_EyeOpening
1..1 gCS_EyeOpening
Glasgow_Coma_Scale_Total
component1
classCode*: <= OBS moodCode*: <= EVN code: CD CWE [..] <= LogicalObservationIdentifierNamesAndCodes "LOINC 9269-2" derivationExpr: ST [0..1] "sumscore" effectiveTime: GTS [0..1] value: INT [0..1] interpretationCode: SET CWE [0..*] <= ObservationInterpretation "score <=8 ernstig letsel; score tussen 9 en 12: matig hersenletsel; score tussen 13 en 15: licht hersenletsel." methodCode: SET CWE [0..*] <= ObservationMethod "LEGIT+PARAL+TUBE+PARTUB"
typeCode*: <= COMP
classCode*: <= OBS moodCode*: <= EVN code*: CD CWE [1..1] <= LogicalObservationIdentifierNamesAndCodes "9267-6" effectiveTime: TS [0..1] value*: CS CWE [1..1] <= GCS_E methodCode: SET CWE [0..*] <= ObservationMethod (4=spontaan, 3=op spraak, 2=op pijnprikkel, 1=geen, C = niet vast te stellen)
GCS_Motor
1..1 gCS_Motor
component2 typeCode*: <= COMP
classCode*: <= OBS moodCode*: <= EVN code: CD CWE [0..1] <= LogicalObservationIdentifierNamesAndCodes "9268-4" effectiveTime: TS [0..1] value*: CS CWE [1..1] <= GCS-M ( ) methodCode: SET CWE [0..*] <= ObservationMethod (6=volgt commando op, 5=lokaliseren van de pijn, 4=terugtrekken, 3=abnormaal buigen, 2=strekken, 1=geen, P=paralyse.)
1..1 gCS_Verbal
component3 typeCode*: <= COMP
GCS_Verbal classCode*: <= OBS moodCode*: <= EVN code: CD CWE [0..1] <= LogicalObservationIdentifierNamesAndCodes "9270-0" effectiveTime: TS [0..1] value*: CS CWE [1..1] <= CGS-V methodCode: SET CWE [0..*] <= ObservationMethod (5 = georienteerd, 4 = verward, 3 = inadequaat, 2 = onverstaanbaar, 1 = geen, T = Trace)
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Nictiz set van 100 zorginformatiemodellen • 2003-2005
formaat van CEN/ISO 13606 archetypes, (meta informatie, evidentie, data elementen, logisch model. • Maar gezien landelijk traject NL, logisch niet op archetypes gebaseerd maar HL7 v3 • Veel data elementen, granulair, afgestemd op evidence based richtlijnen en wetenschappelijke gevalideerde assessment schalen / score lijsten. 7
The aim of the Barthel Index is to capture and follow, in a valid and reliable way, the daily activities of the patient, especially the level of depending on help (Mahoney & Barthel, 1965). Continence of Bowels Barthel_Index BathingDomain data, Vocabulary and D-MIM Mapping classCode*: <= OBS (BarthelR01V1E)
Barthel index
classCode*: <= OBS moodCode*: <= EVN code: <= ActCode "BrtlD510" effectiveTime: GTS [0..1] value*: INT [1..1] methodCode: <= ObservationMethod (0 = dependent; 1 = independent)
Variables
DMIM
OBS
Barthel Index Stairs totalclassCode*: score<= OBS moodCode*: <= EVN code:version! <= ActCode "BrtlD460" Dutch
Barthel Index v1E
attribute
Vocabulary Data type Cardinality 1..1 continence of Bowels component1 HL7 component10 Barthel_Index typeCode*: <= COMP
1..1 bathing
typeCode*: <= COMP
value
effectiveTime: GTS [0..1] value*: INT [1..1] methodCode: , CWE [0..1] (0 = unable; 1 = needs help (verbal, physical, carrying aid) ( )
classCode*: <= OBS
moodCode*: <= EVN INT 1..1 code: <= ActCode "Barthel-index" derivationExpr*: "Sumscore" effectiveTime: TS value*: INT [1..1] interpretationCode: <= ObservationInterpretation "0-9 seriously limited, 10-19 moderately limited, =>20 independent"
1..1 stairs
bowels
OBS
valuetypeCode*: <= COMP INT
1..1
bladder
OBS
value
1..1
Dressing/Undressing
classCode*: <= OBS moodCode*: <= EVN code: <= ActCode "BrtlD540" effectiveTime: GTS [0..1] value*: INT [1..1] methodCode: <= ObservationMethod ((0 = dependent; 1 = needs help but can do about 50% himself; 2 = independent.)
grooming
toilet use feeding
Mobility
OBS
OBS
OBS
component9
value
INT INT
1..1 dressing/Undressing
valuecomponent8 INT
value
INT
CVA-KIS
1..1 controlling Bladder
component2
1..1
”
typeCode*: <= COMP
”
1..1
typeCode*: <= COMP
classCode*: <= OBS moodCode*: <= EVN code: <= ActCode "BrtlD450" effectiveTime: GTS [0..1] value*: INT [1..1] ( ) 1..1 mobility methodCode: <= ObservationMethod (0 = immobile or < 50 yards; 1 = wheelchair independent, component7 including corners, > 50 yards; 2 = walks with help of one typeCode*: <= COMP person (verbal or physical); 3 = independent (but may use any aid; for example, stick) > 50 yards)
” 1..1 personal Toilet
component3
”
typeCode*: <= COMP
1..1
” ”
transfers
OBS
value
INT
1..1
mobility
OBS
value
INT
1..1
dressing
OBS
value
INT
1..1
stairs
OBS
value
INT
1..1
”
1..1 toilet
component4
typeCode*: <= COMP
” ”
Transfer
bathing
moodCode*: <= EVN code: <= ActCode "BrtlB525" effectiveTime: GTS [0..1] value*: INT [1..1] methodCode: <= ObservationMethod ((0 = Incontinent; 1 = Needs help / accidents; 2 = Able to control and no accidents.)
Code
BarthelclassCode*: <= OBS index Controlling Bladder
Example 12
moodCode*: <= EVN code: <= ActCode "BrtlB6202" effectiveTime: GTS [0..1] value*: INT [1..1] methodCode: , CWE [0..1] = continent (((0 = incontinent or catheter; 1 = Occasional accidents (max. 1 time per 24 hours) (for more than 7 days)
BrtlB525
PersonalBrtlB6202 Toilet classCode*: <= OBS moodCode*: <= EVN code: <= ActCode "BrtlD520" effectiveTime: GTS [0..1] value*: INT [1..1] methodCode: ) CWE [0..1] <= ObservationMethod (0 = needs help; 1 = independent (face, hair, teeth, shaving)
BrtlD520
BrtlD530
BrtlD550
Toilet use
classCode*: <= OBS moodCode*: <= EVN code: <= ActCode "BrtlD530" effectiveTime: GTS [0..1] value*: INT [1..1] methodCode: ) CWE [0..1] <= ObservationMethod ((0 = dependent; 1 = needs help but can do some parts on his own; 2 = independent (can get on and off, dressing and undressing, wipe)
BrtlD420 BrtlD450
BrtlD540
BrtlD460
Eating
OBS
classCode*: <= OBS moodCode*: <= EVN code: <= ActCode "BrtlD420" effectiveTime: GTS [0..1] value*: INT [1..1] methodCode: , CWE [0..1] = independent. ) (0 = not able to (not independent) (1-2 people physical) (physical or with words)
value
INT
1..1 transfer
1..1
” 1..1 feeding
component6
component5
typeCode*: <= COMP
typeCode*: <= COMP
BrtlD510
classCode*: <= OBS moodCode*: <= EVN code: <= ActCode "BrtlD550" effectiveTime: GTS [0..1] value*: INT [1..1] methodCode: 1 CWE [0..1] (0 = unable; 1 = needs help cutting, spreading butter, etc., or requires modified diet; 2 = independent ) ( )
2006: Snomed CT? Yes, if.. • In
opdracht van Nictiz CVA zorginformatiemodellen voorzien van Snomed CT codes
Screening in Europe
2006: Detailed Clinical Models workshop post HL7 • Georganizeerd
door Intermountain Health
(IMH) • Geen “Dutch input” • IMH voorbeelden ondersteunen enterprise system architecture (25% van alle NL zorg) • Interesse in HL7 gemeenschap internationaal • HL7 Keulen: Nictiz verzoekt om DCM projecten te starten in SDO’s HL7 / CEN en ISO. 10
2007 HL7 & ISO projecten • ISO
TS 13972: hoe Detailed Clinical Models te maken, welke onderdelen, welke model eisen, patient veiligheid • HL7 project 320: Top 10 of DCMs. • Input Nictiz: 10 meest gebruikte zorginformatiemodellen / HL7 v3 berichten inhoud.
# 11
2009 • Nictiz
set van 26 DCMs voor diabeteszorg • HL7 v3 specificatie levert te veel schema’s op • Keuze: UML of OWL? • Ivm tools en implementaties: UML • Review DCM rond de wereld:
Screening in Europe
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2008-2011 • JGZ:
DCM van Wiechen, Oor, Oog, DMO, inhoud DD JGZ • Parelsnoer 50 DCM, representeren research data, long term datagebruik • SHB: 10 DCM huisarts: externe onderbouwing evidentie voor waarom van data collectie • Perinatale registratie: HL7 v3 berichten maken (3 dagen ipv 3 maanden).
Methode NEN normcommissie • Bottom
up analysis of data elements from information view only (Blobel, 2006, NEN, 2008) – Data
type – Slot binding to code – Concepts – Relationships between concepts • Not
the full placement in existing reference information models • Top 10 modeled in DCM - UML, HL7 template and OpenEHR archetype Goossen, W.T.F., Goossen-Baremans, A.T.M., (2010). Bridging the HL7 Template – 13606 Archetype gap with Detailed Clinical Models. In: C. Safran et al. (Eds.) MEDINFO 2010. Stud Health Technol Inform. 2010;160(Pt 2):932-6.
2012 CIMI Standard Terminologies
CEM
V2 “|” LRA V2 XML HTML
CEMs
V3 XML DCMs
CDA Templates
V3 Next
Shared Models
Realm Specific Realm Specializations Specific Realm Specializations Specific Realm Specializations Specific Realm Specializations Specific Specializations
Shared Terminology
Translators Translators
Translators
UML ADL
Registry(s)
openEHR Archetypes
CDA OWL
CEN Archetypes
LRA Models
CMETs, HMDs RMIMs
Initial Loading of Repository # 15
CDISC SHARE
CEN Archetype
SOA Payload
Versimpeld DCM opbouw
Huff, 2011
DCM voorbeeld
Kies alleen wat je nodig hebt Maar gebruik de standaard data, data types, code en valueset
DCM ISO TS 13972: 2015 core 1. Medical knowledge: concept, target population, evidence, instruction, interpretation
2. Data elements
3. Unique codes, Snomed CT etc
4. Meta information:
• Author • Coder •Versioning
5. Governance
DCM Management ISO TS 13972 DCM QMS Management
Clinical Requirements
DCM Process Monitoring & Improvement
Stakeholder Participation
DCM Development Processes
DCMs
Clinician Acceptance, Adoption & Usage
DCM Governance
2011 DCM & PRN HL7 v3 bericht DCM voor gegevens invoer systeem A
DCM: Opslag in systeem A
A
1 CareProvision
2 Person
EntryPoint
3
Care Statem ent Observation Choice Procedure
De heer Vraagmaarraak, geboren, 09071978 en wonend te Deurne, is sinds het overlijden van zijn vrouw niet goed meer in staat om voor zijn eigen eten te zorgen. Tevens denkt de heer Vraagmaarraak dat het huishouden niet zijn taak is. Maar hij is door beperkingen in de ADL hiertoe ook niet goed in staat. Er wordt gekeken daar de maaltijdendienst en 1 keer per week huishoudelijke verzorging. Cliënt nummer 213757
Provide r Person
Signalering Bericht Systeem B DCM based opslag in systeem B
B
4
1 Patient orRelated orProvider
Patient Medication
DCM based gegevens bekijken systeem B
Person
Encounter
5
3
CareProvision
2
Map to DCM based HL7 v3 model
EntryPoint
Person
DCM input in XML Bericht Zender
DCM in Gegevenscommunicatie
Procedure
4 Patient orRelated orProvider
5
Patient Medication
Provide r Person
<subject> <Patient> <streetName> Maassingel 82 <postalCode> 6678 II DEURNE <statusCode code="active"/> M P <prefix qualifier="VV"> v Vraagmaarraak
Care Statem ent Observation Choice
<subject> <Patient> <streetName> Maassingel 82 <postalCode> 6678 II DEURNE <statusCode code="active"/> M P <prefix qualifier="VV"> v Vraagmaarraak
Person
Encounter
Translate via HL7 v3 model & DCM DCM in XML Bericht Ontvanger
DCM QC DCM gebruik voor Registratie en rapportage Continuiteit van zorg
Kwaliteitsindicatoren
Epidemiologie
Primaire proces
Beslissingsondersteuning
Clinical trial
Management Financieel
DCM medicinal product
Identificatie van medicijnen
22
HL7 v3 payload DCMs: PRN, 2011
PRN/PAN Data Ware House Bron Systemen
Doel Systemen
Metadata: data definities: ART-DECOR, PRN Kernset, PRN 1.4, CRS en Bron e DCM . Gebruik: en Policies EPD’s 1Consent Clie nt PGD
HL7 v3 / DCMs based registratie, 2015
Bron EPD’s HL7 v3 PRN & PAN overlede n kind overlede Kraa n mmoeder zorg
Ferti liteit
.... n
en 2e lijn Aanleveri ng verloskun de HL7 v3 PRN kernset Perinatolo gie 2.2
Bron EPD’ s 2e HL7 v3 LNR / LNF
Huisart sen Via HL7 v3 Enq
uete PRN/ s PAN ontva ngststatio n Alle invoe r Via Bron Porta EPD’s al 2e HL7 v3 Aanvull ende PRN items
Historisch Archief + BSN Pseudonie m
Data Definities Referentie Systeem
Zor
PRN/PAN Data Store & betekenis: -Vrouw en Kind -Professionals - Organisaties -Zorgketen - Volledige PRN dataset -Case reports -Enquetes -PARS
Promise g& 3 afz. 1 TTP gecombine erd BSN pseudonie Versleutelscript m based
PRN Jaarcijfers
Spiegelinfor matie Indicatoren
Wetenschapp elijk onderzoek
Toekomst: ....n
Perinatale audit © [email protected]
Toepassi ngen Jaarbo eken PRN Insig ht Indicat oren ZiZo/ CBS Eurocat / Peristat / Epidemi ologie Etc ….n
Audit rapport ages
Actuele situatie • • • • • • • •
NFU / Nictiz project => vervolg lezing UMCG DCM gebruik in EPD en e-Measure NEN DCM QC: DCM repository& keurmerk ISO publicatie TS 13972: 2015 DCM Clinical Information Modeling Initiative onderdeel van HL7 Int Tool suite beschikbaar waarmee werk veel sneller en beter kan worden gedaan openMedicine DCM medicinal product Perined DWH en datamarts gebaseerd op DCM
Hartelijk dank Dr William Goossen, voorzitter NEN 303006 [email protected]
